Basic Information
| Provider Information | |||||||||
| NPI: | 1699763409 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CORBETT | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 710 N NILES AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466171924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5746471610 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1708 HIGH ST | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466132633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5744004418 | ||||||||
| FaxNumber: | 5742329550 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2005 | ||||||||
| LastUpdateDate: | 02/01/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 71001141A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LW0102X | 71001141A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
| ID | Type | State | Issuer | Description | 000000789430 | 01 | IN | BCBS CENTENNIAL | OTHER | 000000365101 | 01 | IN | BCBS BMG CENTRAL | OTHER | 200044860 | 05 | IN | MEDICAID | 500029743 | 01 | IN | RR MEDICARE | OTHER |